Aims We determined whether blood pressure (BP) lowering
by perindopril was related to its benefit in the EUROPA
study.
Methods and results Twelve thousand two hundred eighteen
patients with documented coronary artery disease
received perindopril 8 mg once daily or matching placebo
after a 4-week run-in period in which all patients received
perindopril. Patients were excluded if systolic (S) BP was
>180 or <100 mmHg. Mean age was 60 years (range 26–
89). 27% had a history of hypertension. After 4.2 years of
follow-up, the primary endpoint (cardiovascular death,
nonfatal myocardial infarction, or resuscitated cardiac
arrest) was observed in 603 (9.9%) placebo versus 488
(8.0%) perindopril patients [20% relative risk reduction
(RRR), CI 9–29%, P=0.003]. There was no interaction
between baseline SBP levels (using JNC-7 cutoff values)
and treatment effect. If anything, the greatest RRR of the
primary endpoint (32%) occurred in patients with the
lowest SBP (<120 mmHg) in whom perindopril did not
reduce SBP. Also, RRR during blinded treatment was
comparable, irrespective of whether BP decreased or not or
of the extent of BP reduction during perindopril treatment.
Conclusion The treatment benefit in EUROPA cannot be
fully explained by baseline BP or BP reduction with
perindopril. Other mechanisms including direct anti-atherosclerotic
effects of ACE inhibition may play a role.
Key words Blood pressure . Coronary artery disease .
Secondary prevention . Perindopril .
Anti-atherosclerotic properties

Aims We determined whether blood pressure (BP) lowering
by perindopril was related to its benefit in the EUROPA
study.
Methods and results Twelve thousand two hundred eighteen
patients with documented coronary artery disease
received perindopril 8 mg once daily or matching placebo
after a 4-week run-in period in which all patients received
perindopril. Patients were excluded if systolic (S) BP was
>180 or <100 mmHg. Mean age was 60 years (range 26–
89). 27% had a history of hypertension. After 4.2 years of
follow-up, the primary endpoint (cardiovascular death,
nonfatal myocardial infarction, or resuscitated cardiac
arrest) was observed in 603 (9.9%) placebo versus 488
(8.0%) perindopril patients [20% relative risk reduction
(RRR), CI 9–29%, P=0.003]. There was no interaction
between baseline SBP levels (using JNC-7 cutoff values)
and treatment effect. If anything, the greatest RRR of the
primary endpoint (32%) occurred in patients with the
lowest SBP (<120 mmHg) in whom perindopril did not
reduce SBP. Also, RRR during blinded treatment was
comparable, irrespective of whether BP decreased or not or
of the extent of BP reduction during perindopril treatment.
Conclusion The treatment benefit in EUROPA cannot be
fully explained by baseline BP or BP reduction with
perindopril. Other mechanisms including direct anti-atherosclerotic
effects of ACE inhibition may play a role.
Key words Blood pressure . Coronary artery disease .
Secondary prevention . Perindopril .
Anti-atherosclerotic properties